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Payer/Provider Collaboration in the Post-Reform World. Pat Hemingway Hall President & CEO Health Care Service Corporation. Who is HCSC?. 4 th Largest U.S. Health Insurer. 13 Million Members. Who is HCSC?. We Have a Great Health Care System. - PowerPoint PPT Presentation
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Payer/Provider Collaboration
in the Post-Reform WorldPat Hemingway HallPresident & CEOHealth Care Service Corporation
2
Who is HCSC?
13 Million Members 4th Largest U.S. Health Insurer
3
Who is HCSC?
4
We Have a Great Health Care System
Highly trained physicians and health care professionals
World-class teaching hospitals
Advanced emergency medicine
Continual innovation
Complex diagnostic capabilities
Nobel prize winning medical research
Leading-edge data analytics
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Change, or Change Will Change You
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OMG!
ACO
HMO PCMH
IOCP
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Guiding Principles
The goal of any new model is to improve the quality, safety and experience of the care of members while lowering cost trend.
The parties must share a well-defined vision and core values.
The strengths, experience and capabilities of each party needs to be recognized.
Health care is local and there is no single model.
Data exchange and transparency are key ingredients for achieving objectives.
88
The Blues
2011 Care Delivery Initiatives
* Based on latest Plan surveys, programs are either currently in market or in development
Development Lab Launched
Pay-for-Performance Program*PCMH Pilot
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HCSC
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Blue Cross Blue Shield of Texas Setting Up ‘Medical Home’ ProgramAdvocate Health Care, Illinois Blues
Agreement Focusing on Improving
Quality, Bending Cost Curve
Health Plans Use Diabetes Disease Management to Reduce Costs and Improve Health
Illinois Blues, Hospitals in Quality PactInsurer Pledges $4 Million to Reduce Readmissions
Texas Hospital Association
Launches Patient Safety Institute
Blue Cross
and Blue Shield of Texas
Is Founding Underwriter
CareFusion, Blue Cross Create Illinois Hospital Quality Initiative to Help Eliminate Health Care Infections
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Proven Models - HMO Illinois
Delivering patient-centered care for 28 years
Grandfather of medical home/ACO models of today
Global payment built around savings
Primary care physician-guided care, which delivers verifiable results in improved member health
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Proven Models - HMO Illinois
Value vs. Broad PPO:
Demonstrably higher
quality with a total annual physician incentive payout of
$70.2M
Cost: 27.6%27.6%
lower PMPM
Overall Member Satisfaction:
92.2%92.2% vs.vs. 91.5%91.5%
Over Over 800,000 800,000 MembersMembers
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Goal: Reduce the incidence of hospital acquired infections
Partnership – BCBSTX and 36 Select Hospitals
HCSC provides technology (surveillance tool) to identify correctable process breakdowns
Proven Models - Texas Hospital Quality Initiative (THQI)
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Proven Models - Texas Hospital Quality Initiative (THQI)
Since July of 2009, hospitals participating in program have:
Reduced the occurrence of hospital acquired infections by 6.59%
Prevented 1,232 patients from acquiring an infection
Eliminated $14 million in hospital direct cost
Avoided over 10,965 patient days
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Proven Models – Bridges to Excellence
Goals: Help patients get healthier, help the best clinicians build their practices, and help insurers and employers manage costs better.
Diabetes Care Recognition Program HCSC has identified 331 physicians with high numbers of diabetics
• Pay physician $100 per patient, per year
13,344 participating members Suite of tools provided to assist in diabetic management NCQA recognition of participating physicians Physicians required to submit biometric data
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Proven Models – Bridges to Excellence
Results BTE physicians deliver care with 10-15% less cost than non-BTE
physicians Savings of $37 PMPM or $4.4 million annually Demonstrated clinical improvement in BP, LDL, HbA1c,
Ophthalmologic and podiatry exams, Nephropathy assessments
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New Models - Intensive Outpatient Care Program (IOCP)
Goal: Improve quality of care, reduce cost of care and enhance the experience of complex, chronically ill patients.
Targets the 10-15% highest risk patients
Highly coordinated team-based care
Embedded RN to coordinate care and intensively manage a small panel of patients
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New Models - Intensive Outpatient Care Program (IOCP)
HCSC’s Role
Identification of high-risk members and attribution to primary care provider
Provision of actionable data to provider
Reimbursement of program through: PMPM care management fee Shared savings Fee for service
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New Models - Intensive Outpatient Care Program (IOCP)
One Employer’s Experience
High levels of quality of care
Improvement in patient experience
Higher levels of functioning, productivity and presenteeism
Lower utilization – fewer emergency visits and hospitalizations
Increase in office visits (positive), pharmacy use, behavioral health
20% reduction in per-patient cost
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New Models - ACO Shared Savings Agreement
Goal: Improve the quality, safety, and affordability of patient care by aligning incentives and leveraging the synergies of the partners
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Bloomington, IL (1 hospital)
Bloomington, IL (1 hospital)
Where?
• Three-year (2011 – 2013) shared savings PPO agreement with upside and downside risk
• Three-year global risk HMO agreement
What?
Who?• 10 hospitals and 2700 physicians• 250,000 attributed Blue Cross PPO
lives• 120,000 Blue Cross HMO lives• $2,000,000,000 annual Blue Cross
volume
Advocate Health Care
How?Exceed threshold medical cost trend better than network and meet patient quality, safety, and satisfaction metrics THEN share in savings.
Metro Chicago, IL (9 hospitals)
Metro Chicago, IL (9 hospitals)
New Models - ACO Shared Savings Agreement
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New Models - ACO Shared Savings Agreement
Personal Personal PhysicianPhysician
Acute Episodic Care Acute Episodic Care
(ex. Surgery)(ex. Surgery)
PPOTotal BCBSIL
Members seeking care at the ACO
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New Models - ACO Shared Savings Agreement
PPO
2011 2012 2013
0%
4%
8%
Perc
ent M
edic
al T
rend
10%
6%
2%
Blue Cross Share
ACO ShareNetwork Trend
ACO w/Actual Incentive
ACO Actual
Illustrative Only
2323
New Models - ACO Shared Savings Agreement
Hospital readmission rates
Hospital readmission rates
Ambulatory care sensitive admission rates
Ambulatory care sensitive admission rates
Never eventsNever events
Hospital acquired conditions
Hospital acquired conditions
Avoidable hospital daysAvoidable hospital days
Appropriateness of advanced imaging utilization
Appropriateness of advanced imaging utilization
Clinical Quality Measures
Patient satisfactionPatient satisfaction
Access to outpatient physician visits
Access to outpatient physician visits
Patient Experience
• Aligned incentive to encourage innovation in care delivery and process redesign
Financial penalties for degradation in any of these measures
Financial penalties for degradation in any of these measures
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Guiding Principles
The goal of any new model is to improve the quality, safety and experience of the care of members while lowering cost trend.
The parties must share a well-defined vision and core values.
The strengths, experience and capabilities of each party needs to be recognized.
Health care is local and there is no single model.
Data exchange and transparency are key ingredients for achieving objectives.
25
Providers and payers can work together to transform our system.
Change – or change will change you.
Conclusion
